Anesthesia Services and the OIG Work Plan

Every fiscal year, the US Department of Health and Human Services (HHS) Office of Inspector General (OIG) releases a Work Plan that consists of reviews of various HSS programs and operations in order to ensure that HHS programs are functioning efficiently and with integrity. The HHS is a massive department that affects and manages everything from the nation’s food and drug supply, stockpiles of pharmaceuticals for emergency use, and the operation of health insurance, and so this Work Plan aims to keep these numerous programs accountable for their operations, as well as to assess the current plans of action.

The OIG states that the Work Plan allows for methods to combat waste, fraud, and abuse in these HHS programs. The OIG also reported that due to the Work Plan and reviews implemented during the fiscal year of 2015, they expected astounding recoveries of funding—more than $3 billion total, with about two-thirds coming from recoveries from investigative work, and the other third coming from recoveries in audit work (5).

While these reviews look to manage programs effectively across the multitude of departments within HHS, anesthesia services are also strongly impacted. Specifically, in the recent November 2015 publication of the 2016 Work Plan, two items were released in regards to anesthesia services. Both of these items were related to the Part B portion of the Medicare Plan, which covers medically necessary services (services needed to diagnose or treat one’s medical condition) and preventive services (services to prevent illnesses, or detect it at an early stage). Besides anesthesia services, Part B also provides coverage for clinical research, ambulance services, mental health, and durable medical equipment (DME).

The first item is a continuation of a review established by the HHS in the 2013 OIG Work Plan for anesthesia services. The review is two-pronged: the HHS would review Medicare Part B claims for “personally performed anesthesia services to determine whether they were supported in accordance with Medicare requirements”, and would also determine whether “Medicare payments for anesthesia services reported on a claim with the ‘AA’ service code” (1). This service code refers to who provided this service—AA corresponds to an Anesthesiologist’s Assistant, while there are also different service codes, like CRNA, which stands for Certified Registered Nurse Anesthetists (4). Essentially, this review ensures that the correct service code modifier on a Medicare claim will be reported. The consequences of an incorrect service code would lead to Medicare’s paying a higher amount, which is a form of governmental waste that the HHS would hope to avoid.

The second item is a new plan for a different review, introduced for the first time in the 2016 edition of the Work Plan. This new service confirms that a beneficiary who received anesthesia also underwent a related Medicare service that required such anesthesia (1). This also ensures that Medicare avoids paying for services that are not covered, those that are not “reasonable and necessary” (1).

In combination, these two new items indicate that the OIG continues to place strong emphasis in correct coding and billing of anesthesia services that are provided from various sources. According to the American Society of Anesthesiologists, in order to assure compliance, “anesthesia practices should conduct periodic reviews” and “confirm that there is appropriate documentation to support the claims filed to receive payment for services” (2).